Liver Transplant in India

Liver is a vital part for humans; it plays a crucial role in metabolism process. If the liver is damaged by
any means the victim cannot survive. The best option for him/her would be Liver Transplant. The article
Liver Transplant in India comprises of information regarding liver functioning, signs of liver failure, liver
donation, Liver surgery. Hope this article can bring awareness regarding liver transplant to all readers.

LIVER FUNCTION

The liver is a vital organ, which means that you cannot live without it. The liver performs many critical
functions, including the metabolism of toxins and drugs, the elimination of degradation products of
normal metabolism (eg, the removal of bilirubin and ammonia from blood), and the synthesis of many
enzymes and proteins (blood coagulation factors).

Blood enters the liver from two channels, the portal vein and hepatic artery, providing nutrients and
oxygen to liver cells, also known as hepatocytes, and other name is bile ducts. The blood leaves the liver
through the hepatic veins that flow into the inferior vena cava that immediately enters the heart. The
liver produces bile, a liquid that helps to eliminate metabolic waste and toxins through intestine and
dissolve fats. Each hepatocyte creates bile and excretes it into microscopic channels that join to form
bile ducts. Like tributaries that join to form a river, the bile ducts join together to form a single “hepatic
duct” that brings bile into the intestine.

WHO NEEDS A LIVER TRANSPLANT?

Liver transplantation surgically replaces a diseased or failing liver with a healthy, normal liver. Currently,
transplantation is the only cure for liver failure because no machine reliably provides all the functions of
the liver. People who need a liver transplant usually have one of the following conditions.

ACUTE HEPATIC INSUFFICIENCY

Acute liver failure, also known as fulminant hepatic failure, occurs when a previously healthy liver is
massively injured with clinical signs and symptoms of liver failure. A number of things can lead to acute
liver failure, but the most common causes are ingestion of a toxin such as fungi poisonous or an
idiosyncratic reaction, overdose of acetaminophen, viral infections.

The characteristic of this condition is the development of confusion (encephalopathy) within eight
weeks after the onset of yellowing of the skin (jaundice). The confusion occurs because the toxins
usually metabolized by the liver accumulate. Patients with acute liver failure can die within days if not
transplanted. These patients are classified as absolute priority (status I), which places them at the top of
the waiting lists for the liver of a donor.

CHRONIC HEPATIC INSUFFICIENCY

The liver has a remarkable ability to repair itself in response to an injury. Nevertheless, repeated lesions
and repairs, usually over many years and even decades, heal the liver permanently. The final stage of
healing is called cirrhosis and corresponds to the point where the liver can no longer repair itself. Once a
person has cirrhosis, they may begin to show signs of liver failure. This is called decompensated liver
disease. Although medications can reduce symptoms caused by liver failure, liver transplantation is the
only permanent cure.

SIGNS OF LIVER DAMAGE

Gastrointestinal bleeding: As the liver becomes more resistance, scarred to portal blood flow increases,
resulting in increased pressure in the portal venous system. This portal hypertension requires alternative
ways for the blood to return to the heart. The small veins in the abdomen, but outside the liver, then
become enlarged and thin-walled because of the abnormally high amount of blood that passes through
them under increased pressure. These fragile veins, called varicose veins, often line parts of the
gastrointestinal tract, especially the stomach and esophagus, and are likely to rupture and bleed. When
bleeding takes place in the intestinal tract, it can be fatal.

FLUID RETENTION

A function of the liver is to synthesize many of the circulating proteins in the blood, including albumin.
Albumin and other proteins in the blood stream retain fluid in the vascular space by exerting what is
known as oncotic (or osmotic) pressure. In case of hepatic insufficiency, the low albumin levels cause
the liquid to come out of the blood which cannot be reabsorbed. The fluid accumulates in the body
cavities and tissues, most often in the abdominal cavity, called “ascites”. The fluid can also accumulate
in the thoracic cavity or in the legs. Fluid retention is treated first of all by a strict limitation of the
dietary salt supply, then by drugs (diuretics) which force the loss of salt and water by the kidneys and
finally by intermittent drainage by insertion of a needle in the abdominal or thoracic cavity.

ENCEPHALOPATHY
The inability of the liver to remove ammonia and other toxins from the blood allows these substances to
accumulate. These toxins cause cognitive dysfunction that ranges from sleep-wake cycle disorders to
mild coma confusion.

JAUNDICE

One of the main functions of the liver is to eliminate the breakdown products of hemoglobin. Bilirubin is
one of those degradation products treated and excreted by the liver. In cases of hepatic failure, bilirubin
is not eliminated from the body and bilirubin levels increase in the blood. The skin and all the tissues of
the body then take on a yellow color.

CAUSES OF CHRONIC LIVER INJURY

VIRAL HEPATITIS

HEPATITIS B

Around 5% of all liver transplants in India happens because of hepatitis B but represents a higher
proportion of liver transplants in other parts of the world, including Australia / New Zealand.

HEPATITIS C

Most of the liver transplants in India happens because of hepatitis C, affecting nearly 50% of all liver
transplant recipients.

ALCOHOLIC LIVER DISEASE

Hepatic impairment due to alcohol abuse is the second most common indication of liver transplantation
in India. Most centers require a minimum of six months of abstinence, often as part of a recognized
addiction treatment program such as Alcoholics Anonymous, as a condition of registration for
transplantation.

METABOLIC LIVER DISEASE

Nonalcoholic Steatohepatitis (NASH): Deposition of fat in liver cells can lead to inflammation that injures
and heals the liver. Risk factors for the development of fatty liver and NASH include obesity and
metabolic conditions such as diabetes and hyperlipidemia (increased cholesterol). The percentage of
patients transplanted for this disease has increased 35-fold between 2000 and 2005.
HEPATOCELLULAR CARCINOMA

Hepatocellular carcinoma (HCC) is a primary liver cancer, which means that it comes from abnormal liver
cells. CHC rarely occurs in a normal, non-cirrhotic liver. Its incidence is, however, remarkably increased
in the context of cirrhosis and, in particular, certain types of liver diseases leading to cirrhosis. Although
cancer begins in the liver first, as it grows, it can spread to other organs of the victim, a process called
metastasis. Hepatocellular carcinoma is most commonly spread to the bones or lungs. The risk of
spreading out of the liver increases with the size of the cancer.

Liver transplantation definitely cures a patient with HCC, provided that the tumor has not spread
beyond the liver. Because there are many more people in need of liver transplants than organs
available, so specific guidelines called the Milan Criteria have been established to define which HCC
patients can be transplanted. These criteria define the limits of the number and size of tumors that
ensure a very low probability of cancer spreading outside the liver.

WHO ARE NOT CANDIDATES FOR A LIVER TRANSPLANT

There are many people with decompensate liver disease and cirrhosis, but not all are suitable
candidates for liver transplantation. A patient should be in a position to survive the operation and also
potential postoperative complications, reliably take drugs that prevent infections, travel to the clinic
regularly, and undergo laboratory tests and stop drinking alcohol. The conditions listed below are
generally considered absolute contraindications to liver transplantation.

Life expectancy may be reduced due to Serious and irreversible illness

Severe pulmonary hypertension

Cancer that has spread to other organs outside the liver

Uncontrollable or Systemic infection

Abuse of active substances (alcohol and / or drugs)

Unacceptable risk of substance abuse (alcohol and / or drugs)

History of incompletion or adoption to a strict medical course.

Uncontrolled and Severe psychiatric illness

TYPES OF ORGAN DONORS

BRAIN DEAD DONOR ORGANS

Most livers used for transplantation come from dead brain patients. Brain death is usually due to a
major stroke or massive head trauma caused by a penetrating injury (eg example a gunshot wound) or a
blunt injury (for example, accidents). The trauma has stopped all brain functions, although other organs,
including the liver, can continue to function normally.

There are strict definitions as to what constitutes brain death based on the complete absence of any
kind of brain function. Because patients who meet the criteria for brain death are legally dead, they are
appropriate tissue and organ donors. In countries like United States, the family of someone who is brain
dead must give consent for organ and / or tissue donation and in France, consent to organ donation is
presumed and allowed, but the family members have right for objection.

Typically, transplant centers whose patients will receive organs from a particular donor will send a team
of surgeons to procure the appropriate organ. The organ harvesting procedure takes place in an
operating room of the donor hospital. The organs are removed and stored in order to optimize their
state during the period of storage and transport. Each acquired organ is then transported to the
hospitals where the designated recipient is waiting for it.

ORGAN DONORS OF CARDIAC DEATH

Sometimes a patient has a poor neurological prognosis and a devastating brain injury, but does not
meet the strict criteria for brain death in that there is still detectable brain function. In these situation,
the patient’s family may decide to withdraw lifesaving medical support and allow him to die. In such
type of cases, death is treated as cardiac death but not as brain death. Organ donation can happen after
cardiac death but make sure family members must accept it.

It is only after the family’s decision to withdraw support that the patient can be considered for an organ
donation after his death. In this senario, support is withdrawn, according to the wish of family members
and managed by the patient’s physician, and then the patient is allowed to die. The patient’s physician,
who is not involved in any aspect of the organ transplant, is present to determine when the heart stops
beating and the circulation is stopped so that the patient has no sign of life . He or she then declares the
patient’s death.

An urgent operation is then performed to preserve and remove organs for transplantation. This mode of
cardiac death, unlike brain death, causes an increase in organ damage during two periods. The first
period is that between the withdrawal of support from life and death. As the donor’s breathing and
circulation deteriorate, the organs may no longer receive enough oxygen. The second period is minutes
immediately after death and until the organs are rinsed with the preservative solution and cooled. As a
result, livers obtained from cardiac death donors are associated with an increased risk of primary
malfunction or dysfunction of the early organs, thrombosis of the hepatic arteries and biliary
complications.

LIVING DONORS

Although each person has only one liver and would die without it, it is possible to donate part of the
liver for transplantation to another individual. Segmental anatomy (see figure below) allows surgeons to
create grafts of varying size, depending on the recipient’s requirement for liver tissue. Partial livers in
the recipient and donor will develop to provide normal liver function for both individuals.

THE LIVER TRANSPLANT OPERATION

A liver transplant involves the removal and preparation of the donor’s liver, the removal of the diseased
liver, and the implantation of the new organ. The liver has several important connections that must be
re-established so that the new organ can receive blood flow and drain the bile from the liver. The
structures to be reconnected are the the bile duct, the hepatic artery, the portal vein and inferior vena
cava. The exact method of connecting these structures varies depending on the specific anatomy of the
recipient and the anatomy of donor and, in some cases, the recipient’s disease.

For a person undergoing liver transplant surgery, the series of events in the operating room is as follows:

Incision

Evaluation of the abdomen for abnormalities that would prevent liver transplantation (eg, undiagnosed
infection or malignancy)

The native liver is mobilized.(dissection of hepatic attachments to the abdominal cavity)

Isolation of important structures (hepatic artery, common bile duct, portal vein, behind and below the
liver, inferior vena cava above)

Transaction of the structures mentioned and removal of the native sick liver.

Sewing in the new liver: First, venous blood flow is restored by connecting the inferior vena cava and the
portal veins of the donor and recipient. Then, the arterial flow is restored by sewing the recipient and
donor hepatic arteries. Finally, biliary drainage is done by sewing the common bile ducts of the recipient
and donor.

Bleeding need to be controlled

The incision is closed.